[The first 20 years of coronary angioplasty: retrospective and perspectives].
The first coronary angioplasty (PTCA) procedure performed by Grüntzig in Zurich in 1977 was not the beginning but the breakthrough in interventional cardiology. PTCA is today the most frequent of the major interventions in medicine and constitutes an important economic factor. At first the development of PTCA was slow because many European countries postponed invasive assessment of coronary artery disease until the patient was refractory to a combination of drugs. Thus, the early forms of coronary artery disease, optimal for PTCA, were rarely found among the coronary angiograms performed. In the US, facilities for coronary angiography were already expanding in the seventies. They provided the ideal background for PTCA to thrive. Together with Andreas Grüntzig, PTCA moved to the New World in late 1980. Only very recently, the Old World and the Orient have caught up with the US and are now about to assume a leading role. In spite of untiring endeavors, the angioplasty balloon has not been replaced by more sophisticated systems. Only the coronary stent has proved invaluable as a complement to the balloon. After preliminary use in peripheral vessels, the first coronary stent was implanted by Puel in Toulouse on March 28, 1986. In the meantime, the stent has grown to become an integral part of PTCA in about half the cases. Indications for PTCA have not changed significantly since its inception. Success and complication rates, however, have significantly improved. The method is still best applied to single vessel disease. In double or triple vessel disease, it may be preferable to bypass surgery or medical treatment in selected cases where not all main vessels are affected and the total number of lesions does not exceed 3-4. The risk of an abrupt vessel closure during or immediately after PTCA has decreased over time to about 2% currently compared with 7% before the use of stents. Yet it continues to be a hazard to be taken seriously. The risk of recurrence has also diminished in the era of stents but still amounts to 20-40% depending on the situation. Switzerland occupies an important position in Europe today concerning the use of PTCA per head of population. It is in a group with Belgium, France, and the Netherlands running up to the leader, Germany. Since 1993, there have been more PTCA procedures than coronary bypass operations in Switzerland. PTCA is performed today at 5 university hospitals, 9 additional public hospitals, and 9 private clinics. The majority of the procedures are done during the diagnostic study. The total number of coronary bypass operations has continued to increase slightly in spite of PTCA. This documents the fact that true triple vessel disease is still a domain for surgery and that the indication threshold has been shifted to the elderly patient. Therefore, the total need for revascularization procedures has drastically increased. Further growth of PTCA can be predicted unless political measures, such as rationing, reduced credentialing, or drastic cuts in reimbursement are introduced. The recently developed minimally invasive direct coronary artery bypass (MIDCAB) surgery is likely to compete with conventional bypass surgery as much as with PTCA. Its final role remains to be defined. As a side benefit it represents a means of quality control, uniting surgeons and interventional cardiologists in case discussions again with increasing frequency.
Meier
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Universitätsklinik, Inselspital Bern.
D015906:Angioplasty, Balloon, Coronary / Q000379:methods / Q000706:statistics & numerical data / Q000639:trends; D005060:Europe; D006801:Humans; D013557:Switzerland; D014481:United States
Die ersten 20 Jahre der Koronarangioplastie: Rückschau und Ausblick.